[Assessment of velopharyngeal status of postoperative cleft palate patients in silent mode by visual analog scale].

OBJECTIVE: To evaluate the velopharyngeal status of cleft palate patients after operation in silent mode by visual analog scale. METHODS: A total of 82 patients with cleft lip and palate after operation were examined by nasopharyngeal fiber endoscopy with 11 voice samples. The velopharyngeal status was evaluated by three experienced experts using qualitative method and visual analog scale (VAS) method in silent mode. The Spearman correlation relationship was analyzed between VAS value and qualitative grade. The VAS value range of 10 non-nasal consonant voice samples was divided according to qualitative classification. RESULTS: VAS values could accurately reflect the outcome of the qualitative classification. The poorer the velopharyngeal status was, the lower the VAS value, and vice versa. The whole effectiveness of value range was greater than 70%. CONCLUSIONS: VAS values can accurately reflect the outcome of the qualitative classification about velopharyngeal function, and VAS value grading velopharyngeal status is reliable. This study proposed VAS values range standards for different velopharyngeal qualitative classification.

Palatoplasty outcomes in nonsyndromic patients with cleft palate: a 29-year assessment of one surgeon's experience.

The primary objective of cleft palate repair is velopharyngeal competence without fistula. The reported incidence of fistula and velopharyngeal insufficiency (VPI) is variable. Our purpose was to assess the senior surgeon's 29-year palatoplasty experience with respect to incidence of fistula and VPI. Our hypotheses were that VPI is related to (1) age at palatoplasty, (2) cleft palate type, and (3) VPI and palatal fistula incidence decrease with the surgeon's experience. We reviewed the records of all children with cleft palate treated by the senior author between 1976 and 2004. Cleft palate was categorized according to Veau. Palatoplasty was performed on 449 patients, using a 2-flap technique with muscular retropositioning. The mean age at palatoplasty was 11.6 +/- 4.9 months (range, 7.0-46.4 months). The incidence of palatal fistula was 2.9%, and velopharyngeal sufficiency was found in 85.1% of patients. We found a significant association between age at palatoplasty and VPI (P = 0.009, odds ratio, 1.06 [95% confidence interval, 1.02-1.10]). Velopharyngeal insufficiency was also associated with the Veau hierarchy (P = 0.001). Incidence of VPI was independent of surgeon experience (P = 0.2). In conclusion, the incidence of palatal fistula was low. Velopharyngeal insufficiency was associated with increasing age at palatoplasty and with the Veau hierarchy.

SISL (ScreeningsInstrument Schisis Leuven): assessment of cleft palate speech, resonance and myofunction.

This paper presents an assessment protocol for the evaluation and description of speech, resonance and myofunctional characteristics commonly associated with cleft palate and/or velopharyngeal dysfunction. The protocol is partly based on the GOS.SP.ASS'98 and adapted to Flemish. It focuses on the relevant aspects of cleft type speech necessary to facilitate assessment, adequate diagnosis and management planning in a multi-disciplinary setting of cleft team care.

Evaluation of VPI-assessment with videofluoroscopy and nasoendoscopy.

UNLABELLED: The purpose of this study was to investigate how different amounts of visual assessment information influence the recommended treatment for velopharyngeal insufficiency (VPI). Is a patient presented with videofluoroscopy (VF) in lateral projection recommended the same treatment as when frontal projection, nasoendoscopy, or both, are added? Retrospective material with video recorded assessment of VPI was blinded and copied in random order. Each patient was then presented in four separate combinations: VF in lateral projection; VF in lateral and frontal projection; VF in lateral projection and nasoendoscopy; and VF in lateral and frontal projection and nasoendoscopy (all of the available assessment material). The cleft palate team of Göteborg, Sweden, mutually rated velopharyngeal function and recommended action based on the presented material. SUBJECTS: Nineteen consecutive patients (median age 7:5 years, range 4:4-19:7) investigated with VF in lateral and frontal projection and nasoendoscopy during 1997-99 at the cleft palate centre in Göteborg, Sweden. Post operative assessments were excluded. Percent agreement and Kappa calculations were used to compare the different combinations of parts of information to all of the available information. RESULTS: Thirteen of the 19 patients (68%) were recommended the same action regardless of the amount of presented information. Percent agreement (Kappa) between parts and all of the available information: VF in lateral projection 84% (0.75), VF in lateral and frontal projection 79% (0.74), and VF in lateral projection and nasoendoscopy 84% (0.72). CONCLUSIONS: VF in lateral projection is recommended to be the first step in visualising velopharyngeal function, and nasoendoscopy the next when further investigation is required.

Hearing and speech assessment of cleft palate patients after palatal closure. Long-term results.

OBJECTIVE: The goal of this study was the development of a clinical methodology to assess speech and hearing impairment 5 years after the primary surgical repair of the cleft and, further, to determine the relative importance and long-term consequences of each cleft type and age to the velopharyngeal and eustachian tube function in patients who did not undergo pharyngeal flap surgery following primary palatoplasty. MATERIALS AND METHODS: We evaluated with a certain assessment protocol hearing and speech abilities of 42 patients between 5 and 15 years of age: 9 with CP (cleft of the soft and hard palate), 19 with unilateral cleft lip and palate (UCLP), 14 with bilateral cleft lip and palate (BCLP), surgically treated by a team of surgeons using two different surgical techniques between 18 and 24 months of age. ACCORDING TO OUR RESULTS WE WERE ABLE TO EVALUATE: (a) the impact of hearing impairment to the development of speech in these patients. (b) The relation of hypernasality with compansatory articulation. (c) The influence of cleft type, by means of extent of the cleft palatal musculature, to speech integrity. RESULTS: Sixty-nine percent of our patients presented with mild and moderate hearing loss. Hypernasality was observed in 40.5%, compensatory articulation in 28.5% of our patients. CONCLUSIONS: Our findings indicated: (a) a simultaneous appearance of speech and hearing impairment at the same age for each cleft type post-surgically in our patients; (b) that the muscular and vomer complex rather than the anatomic extent of the cleft is a significant factor for speech outcome after surgical repair; and (c) that hypernasality is exacerbated by compensatory articulation.

Retropharyngeal autologous fat transplantation for congenital short palate: a nasometric assessment of functional results.

Seventeen patients (4 to 24 years old; mean, 9.7 years) with mild velopharyngeal insufficiency were treated in our department during the period 1996 to 1999 with augmentation of the posterior pharyngeal wall with autologous fat. The main disorder was a congenital short palate without a cleft, in most cases revealed by adenoidectomy. Four patients had previously undergone pharyngoplasty, and 1 had already been injected in the posterior pharyngeal wall with Teflon paste. All patients had been exhaustively treated with speech therapy, and the result remained unsatisfactory. The functional outcome of the surgical procedure was quantified by acoustic nasometry. The decrease of the nasalance percentage for a standardized spoken passage was significant 1 to 3 months after the fat transplantation, and there was a slight tendency to further reduction of nasality at the late follow-up visit, more than 6 months (average, 9.4 months) after the intervention. The mean value of the nasalance score for the "normal passage" (running speech) then reached the limit of normal values. A long-term follow-up (average, 24.3 months) by telephone questionnaire confirmed the persistence of the beneficial results. Autologous fat seems an excellent alternative for Teflon in this indication. Acoustic nasometry allows a precise quantitative assessment of functional velopharyngeal surgery.

Instrumental assessment and treatment of hypernasality, following maxillofacial surgery, using SNORS: a single case study.

The super nasal oral ratiometry system (SNORS) is a commercially available system which measures both nasal and oral airflow during speech, allowing the very rapid movement of the velum to be measured. SNORS uses a modified oxygen mask, which houses the airflow sensors and microphones, and a standard personal computer. By calculating nasalance (the percentage of airflow that is nasal), an estimation of velopharyngeal closure, which is independent of speech intensity, is achieved. SNORS can be used for objective assessment, where the subject is required to speak a number of words selected to demonstrate velopharyngeal function. SNORS also provides biofeedback, using a simple realtime display of nasal and oral airflow. Velopharyngeal insufficiency (VPI) is the inability to make adequate velpharyngeal closure, and may be the result of either neurological or, as in this case, structural abnormalities. It results in abnormal speech characteristics, such as omissions, substitutions or weak articulation of consonants, and hypernasality. T.W., a 52 year old male, had very hypernasal speech following extensive maxillofacial surgery, for the removal of a tonsillar carcinoma. SNORS was successfully used as both an assessment and a therapy tool in the treatment of this patient. The effectiveness of conventional speech and language therapy vs. SNORS biofeedback therapy was compared. Initially, while there was some movement of the velum, the patient could not achieve velopharyngeal closure. Conventional therapy aimed to strengthen and improve the function of the velum and following this there was some minimal improvement: the patient could now achieve, but not maintain, closure. Reassessment, following a non-treatment period, showed little further change. SNORS biofeedback therapy was then given. This raised the patient's awareness of his velopharyngeal function, thus helping him to maintain closure, thereby reducing hypernasality. SNORS therapy proved significantly more effective than conventional speech and language therapy, in this case. Further intervention is outlined, and the benefits of multiparameter assessment of speech are discussed.

Identification and assessment of velopharyngeal inadequacy.

PURPOSE: To review current literature with respect to the diagnosis and assessment of velopharyngeal inadequacy (VPI), including present knowledge about the most common causes of VPI. METHODS: Data sources include published reports over the past 20 years derived from computerized databases and bibliographies of pertinent articles and books. Indexing terms used were "velopharyngeal incompetence," "velopharyngeal inadequacy." "velopharyngeal insufficiency." CONCLUSION: VPI is most commonly associated with cleft palate, submucous cleft palate, and following adenoidectomy. The otolaryngologist can prevent the latter by preoperative identification of physical stigmata associated with VPI. Perceptual assessment is the criterion standard for diagnosis of VPI. Multiview videofluorography and flexible nasal endoscopy provide the best direct assessments to help plan and direct the optimal treatment of VPI.

Assessment in the treatment of hypernasal speech with motor neuron disease: a clinical report.

The application of nasal anemometry in this patient's treatment proved to be of value in obtaining an objective assessment of this intervention. Nasal anemometry may be of use in other situations, for example, (1) in preassessment and postassessment of cleft palate surgery and surgical interventions to improve the velopharyngeal seal (such as pharyngoplasty), (2) in the evaluation of nasalized speech with conventional speech therapy, (3) in the evaluation of nasalized speech by use of a palatal training appliance, and (4) in the investigation of snoring.

Revision of the failed sphincter pharyngoplasty: an outcome assessment.

This paper reports results of surgical management of failed sphincter pharyngoplasties that were performed for velopharyngeal dysfunction. Revisional surgery consisted of tightening of the sphincter pharyngoplasty port or reinsertion of sphincter pharyngoplasty flaps following dehiscence. We critique the anatomic abnormalities associated with unacceptable vocal resonance and nasal air escape following sphincter pharyngoplasty and analyze the effect of sphincter pharyngoplasty revision on ultimate speech outcome. The results of initial sphincter pharyngoplasty surgery were evaluated in 46 patients with velopharyngeal dysfunction. Nine (20 percent) of these patients were considered surgical failures because of persistent hypernasality and/or nasal turbulence on perceptual speech evaluation at least 3 months postoperatively. These patients underwent sphincter pharyngoplasty revision and form the basis of this report. All patients who failed sphincter pharyngoplasty initially underwent both preoperative and postoperative perceptual speech evaluations, lateral phonation radiographic studies with still reference views, and flexible nasendoscopic studies. Evaluations of upper airway status were conducted by the same experienced otolaryngologist. Following sphincter pharyngoplasty revision, 7 of 9 (78 percent) patients demonstrated resolution of velopharyngeal dysfunction, and to some degree, all patients managed with revision became hyponasal. The primary cause of failure was partial or complete flap dehiscence; a secondary cause was hypotonicity of the velopharyngeal mechanism. Failure was not correlated with the level of insertion of the pharyngoplasty flaps with respect to the point of attempted velopharyngeal contact. Sphincter pharyngoplasty is an effective means of management for velopharyngeal dysfunction in many patients. The objective of removing the stigmata of velopharyngeal dysfunction without causing upper airway obstruction may not be realistic in some patients with microretrognathia (i.e., Pierre Robin sequence), in whom anatomic constraints predispose to flap dehiscence. Problems with surgical technique contributing to failure appear to be related to experience of the surgeon, and improvement in outcome can be anticipated as the "learning curve" is overcome.